Discussion
COVID-19 is a novel viral illness caused via close contact, respiratory droplets, and aerosolized particles [4, 5]. In the review of the current literature, children appear to display milder clinical manifestations for COVID-19 compared to the adult population [6]. More recently, SARS-CoV-2 virus infections have been associated with Kawasaki like illness with a hyperimmune state and described as a multisystem inflammatory syndrome of children (MIS-C) [7]. 
The Centers for Disease Control and Prevention (CDC) noted that 56% of laboratory-confirmed COVID-19 pediatric cases presented with fever, 54% with cough, and 13% with shortness of breath. Other associated findings are gastrointestinal symptoms, including abdominal discomfort, nausea, vomiting, and diarrhea [8]. Laboratory COVID-19 confirmed pediatric cases can show normal total white blood cell counts with lymphopenia, elevated liver enzymes, lactate dehydrogenase, C-reactive protein, erythrocyte sedimentation rates, and pro-calcitonin levels [9, 10]. 
Pediatric cases of persistent fever and cheilitis often coincide in children with Kawasaki disease. Other associated signs and symptoms are bilateral non-exudative conjunctivitis, cervical lymphadenopathy, mucositis, polymorphous rash, and edema of the hands and feet, all absent in our patient. At the time of our literature review, there have been 15 reported cases of atypical, typical, and incomplete Kawasaki like disease in children in the New York State as of April 29th, 2020. Over 50% of these patients with MIS-C presented in shock and required blood pressure support, while 33% required mechanical ventilation. As of the date of this article, no fatalities were reported [7]. The exact mechanism of COVID-19 infection and this new multisystem inflammatory syndrome remains unclear. 
As of April 2020, the World Health Organization (WHO) noted that 80% of confirmed COVID-19 positive pediatric patients displayed mild symptoms such as fever, non-productive cough, and fatigue and often recovered without requiring hospitalization [11]. This patient presented with fever without an apparent source prompting a partial workup for sepsis. The patient required hospitalization for continued diagnostic workup and empiric treatment. This patient did not develop any respiratory complications from his COVID-19 infection. It is important to now consider COVID-19 as a potential differential diagnosis in addition to routine sepsis workup in pediatric patients presenting with persistent fever without a defined source of infection. Occult infectious etiologies such as bacteremia, urinary tract infection, and meningitis, should not be discounted for patients with persistent fever. Acute cheilitis may be another manifestation of COVID-19, and the occurrence of this finding in febrile children should raise the suspicion of COVID- 19. We suggest testing for COVID-19 for febrile children presenting with cheilitis that is otherwise unexplained.